Southern African Journal of HIV Medicine

ISSN: (Online) 2078-6751, (Print) 1608-9693

Page 1 of 8 Guidelines

Guidelines for the vaccination of HIV-infected

adolescents and adults in South Africa

Authors: Introduction
Sipho K. Dlamini1
Shabir A. Madhi2,3 The introduction of vaccines has been one of the most cost-effective strategies to prevent infectious
Rudzani Muloiwa4 diseases in humans.1 It is estimated that vaccines save 2–3 million lives globally each year (WHO
Anne von Gottberg5,6 and UNICEF 2005). Vaccines are critical in preventing vaccine-preventable diseases (VPDs),
Mahomed-Yunus S. Moosa7 particularly among immunocompromised individuals such as those with HIV infection. HIV-
Susan T. Meiring8,9
Charles S. Wiysonge10,11
infected individuals have impaired host defence (cellular and humoral immunity), and hence
Eric Hefer12 have a greater risk and severity of VPDs than non-immunocompromised populations.2
Muhangwi B. Mulaudzi13
James Nuttall4 Effective antiretroviral therapy (ART) has resulted in HIV infection becoming a chronic
Michelle Moorhouse14
manageable illness. Despite ART, systemic inflammation and immune activation persist in HIV-
Benjamin M. Kagina15,16
infected individuals and are associated with adverse health outcomes.3 Furthermore, immune
Affiliations: reconstitution is incomplete following ART initiation, which might include absence of underlying
1
Department of Medicine, memory responses previously induced through natural infection or early childhood vaccination.
University of Cape Town, Vaccination, and possibly revaccination, could be an important complement to ART in preventing
South Africa
further complications in this population.4
2
South African Medical
Research Council, Respiratory The impact of VPDs in HIV-infected individuals not only relates to the acute phase mortality but
and Meningeal Pathogens also derives from the high prevalence of these diseases in the HIV population, with effects on
Research Unit, Faculty of long-term morbidity and mortality.5
Health Sciences, University
of the Witwatersrand,
South Africa Vaccines enhance immunity against infections that may have been compromised following HIV
infection. The benefits of vaccination in HIV-infected individuals must be weighed against its risks.
3
Department of Science However, in the absence of severe immunosuppression, the majority of routine vaccines, including
and National Research live attenuated vaccines, have been found to be safe for use in HIV-infected individuals.2 At present,
Foundation: Research Chair:
the evidence suggests that vaccination of HIV-infected persons with suppressed viral loads and
Vaccine Preventable
Diseases, Faculty of Health nadir CD4+ counts greater than 200 cells/µL has little or no deleterious effect on immune and
Sciences, University of the inflammatory activation.4,6 The duration of seroprotection for most vaccines has been shown to be
Witwatersrand, South Africa shorter in HIV-infected patients compared to uninfected individuals.7 There are insufficient data to
guide the optimal timing for revaccination or booster vaccination among HIV-infected individuals.8
4
Department of Paediatrics
and Child Health, University
of Cape Town, South Africa
There are no national guidelines for the use of vaccines for HIV-infected people in South Africa.
Establishment of guidelines could contribute to improving vaccine uptake in this population. The
5
Centre for Respiratory national guidelines will also help healthcare workers in decision-making towards vaccinating
Diseases and Meningitis, HIV-infected individuals. The use of vaccines in the HIV-infected is generally safe and causes
National Institute for no harm among patients with CD4+ counts above 200 cells/µL and with very low viral load
Communicable Diseases,
(< 50 copies/mL).9,10 Even among HIV-infected individuals who are severely immunocompromised,
a division of the National
Health Laboratory Services, the majority of non-live vaccines are potentially safe, although the immunogenicity and
Johannesburg, South Africa effectiveness need to be elucidated.
7
Department of Infectious Diseases, Division of Internal Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal,
6
School of Pathology, Faculty South Africa
of Health Sciences, University 8
National Institute for Communicable Diseases, Division of the National Laboratory Services, South Africa
of the Witwatersrand, 9
School of Public Health, University of the Witwatersrand, South Africa
Johannesburg, South Africa 10
Cochrane South Africa, South African Medical Research Council, Division of Epidemiology and Biostatistics, Department of Global
Health, Stellenbosch University, South Africa
11
Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
12
Private Practice, Johannesburg, South Africa
13
Private Practice, Rustenburg Phomolong Medical Centre, South Africa
14
Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
15
School of Public Health and Family Medicine, University of Cape Town, South Africa
Read online: 16
Vaccines for Africa Initiative, University of Cape Town, South Africa
Scan this QR Corresponding author: Sipho Dlamini, [email protected]
code with your
Dates: Received: 12 Feb. 2018 | Accepted: 09 Mar. 2018 | Published: 23 May 2018
smart phone or
mobile device How to cite this article: Dlamini SK, Madhi SA, Muloiwa R, et al. Guidelines for the vaccination of HIV-infected adolescents and adults in
to read online. South Africa. S Afr J HIV Med. 2018;19(1), a839. https://doi.org/10.4102/sajhivmed.v19i1.839
Copyright: © 2018. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License.

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 Page 2 of 8 Guidelines

As part of a comprehensive approach to the management immune responses to influenza vaccines, especially when
of HIV-infected individuals, the Southern African HIV CD4+ cell counts are below 200 cells/µL.14 Despite this,
Clinicians Society aims to promote the use of vaccines in this influenza vaccination is effective in preventing influenza
group. Currently, there are no guidelines on the use of infection and reducing severity of influenza-associated
vaccines among the HIV-infected in South Africa. illnesses among HIV-infected persons.10 Inactivated influenza
Furthermore, suboptimal knowledge among HIV-infected vaccines administered to HIV-infected individuals have been
individuals and healthcare providers undermines the use of found to be safe with a vaccine efficacy of approximately 75%
vaccines in a population that could otherwise benefit most in South Africa, despite a relatively modest immune response
from vaccination. as measured by the haemagglutinin inhibition (HAI) assay.15
Similarly, despite low immunogenicity per HAI assay of
Challenges of vaccination influenza vaccine in HIV-infected compared to HIV-
uninfected pregnant women in South Africa, the vaccine
Challenges faced by the healthcare providers wanting to efficacy was 73% against influenza confirmed illness among
vaccinate HIV-infected individuals include, firstly, a lack of HIV-infected women.16 These studies suggest that the
national guidelines and policies. Secondly, vaccines are not conventional immune read-outs which we use for predicting
generally available at settings where HIV-infected adults vaccine efficacy for inactivated influenza vaccine, that is,
seek care. Furthermore, cost of the vaccines may be a limiting HAI titres ≥ 40, might not be useful and may underestimate
factor in the health system which is already burdened by vaccine efficacy in this population.
various other costs. These barriers impact negatively on the
uptake of vaccines among HIV-infected adolescents and The influenza season in South Africa is variable. It can start as
adults. early as April or as late as July and lasts between 12 and 25
weeks.17
Rationale for the development of
The panel recommends that the trivalent- or quadrivalent-
national guidelines inactivated influenza vaccine be administered between
The epidemiology of HIV disease has changed significantly March and May each year to all HIV-infected persons,
in the last 10 years in South Africa. More people with HIV are irrespective of CD4+ cell count, HIV viral load or pregnancy
living longer as access to ART increases. Associated with this status.
increase in life expectancy is an increased risk of VPDs
despite suppressive ART. Pneumococcal vaccines
Invasive pneumococcal disease (IPD) in HIV-infected
Scope of guideline individuals is a significant cause of morbidity and
These national guidelines for vaccines available for HIV- mortality.18 Even with improved and increased access to
infected adolescents and adults in South Africa have been universal ART in South Africa, the relative risk of having
developed to address challenges of adolescent and adult IPD among the HIV-infected is 35–100 times more than
immunisation in the setting of HIV. The guidelines specifically HIV-uninfected individuals.19,20,21 Available evidence from
focus on the most common VPDs in sub-Saharan Africa Africa suggests that pneumococcal conjugate vaccines
among HIV-infected adolescents and adults. The best (PCV) are effective against the vaccine-type pneumococcal
available evidence has been used to make recommendations disease when given to HIV-infected adults.19,20 In South
on the appropriate use of active and passive immunisation in Africa, PCV has been included in the routine childhood
HIV-infected adolescents and adults. immunisation programme since 2009. Early post-vaccine
impact data from South Africa showed a 40% reduction in

Influenza vaccines vaccine-type IPD over non-vaccine-type IPD in HIV-

infected adults, indicating that there is some indirect
Influenza is a seasonal viral disease that often leads to a high protection to unvaccinated adults.22
morbidity and mortality both nationally and globally.
The mortality from influenza in South Africa is between 6000 However, with such a high burden of disease in the HIV-
and 11 000 deaths every year.11 Individuals who are HIV- infected population, there is a need to consider additional or
infected have a four- to eight-fold risk of influenza and are complementary strategies to prevent pneumococcal disease
1.5 times more likely to die as a result of this than HIV- in HIV-infected adults. An example would be a combination
uninfected individuals.12,13 There are several types of licensed vaccine strategy of the 13-valent pneumococcal conjugate
vaccines against seasonal influenza; only the trivalent vaccine (PCV13) and 23-valent pneumococcal polysaccharide
inactivated influenza vaccine (TIV) is currently available in vaccine (PPV23). This directly increases protection to
South Africa. Vaccination against influenza has been shown serotypes that are in PPV23 but not in PCV13.
to be an effective preventive strategy, and many international
immunisation guidelines recommend vaccination against the Broadly, there are two types of vaccine available for
seasonal influenza in HIV-infected individuals. Evidence use to prevent pneumococcal disease: the pneumococcal
suggests that HIV-infected individuals may have reduced polysaccharide vaccines (PPV) and the PCV. The PPV23 is

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 Page 3 of 8 Guidelines

protective against all-cause pneumonia and pneumococcal data from South Africa show an increased case-fatality rate
disease in HIV-infected adults, although data vary as to of IMD in HIV-infected patients (20% vs. 11% in HIV-
whether the protective benefit is irrespective of CD4+ count uninfected patients) that could be explained by their
above a particular threshold, or dependent on HIV viral load increased odds of bacteraemia compared to meningitis.33
at time of vaccination.23 Results from a randomised placebo-
controlled trial of PPV in HIV-infected subjects conducted in Currently in South Africa, meningococcal disease is a minor
Uganda found an increase in all-cause pneumonia in the contributor to mortality among the HIV-infected, when
vaccine arm.24 As a result, some international guidelines do compared to other infections such as tuberculosis (TB) and
not recommend vaccination with PPV among HIV-infected pneumococcal disease.34 However, the availability of effective
adults with CD4+ counts less than 200 cells/µL. The vaccines against meningococcal disease should warrant the
immunological and clinical efficacy of PPV23 for HIV- use of these vaccines in HIV-infected adults where needed. In
infected adults, particularly in the absence of ART, remains 2016, the ACIP added HIV infection as a high-risk condition
controversial.19 for meningococcal disease, based on the growing body of
evidence supporting an increased risk of meningococcal
A randomised double-blind placebo-controlled trial of PCV7 disease in HIV-infected individuals.30,35 Prospective cohort
in HIV-infected adults in Malawi showed that the vaccine studies or case-controlled studies are needed to evaluate this
was protective against recurrent IPD.19 Other studies have association and further clarify the level of immunosuppression
confirmed the safety and immunogenicity of PCV13 in HIV- at which the increased risk occurs.
infected adults.20 The use of PCV in HIV infection is supported
by studies showing prevention of pneumococcal pneumonia Our recommendation is that, where possible, vaccination
in children and prevention of recurrent IPD in adults.25 should be considered in HIV-infected adults with a CD4+
count above 200 cells/µL. Where resources are limited,
The use of either PCVs or PPVs will be a balance between the routine meningococcal vaccination of HIV-infected adults
resources available to pay for the vaccine and the evidence to should follow the indications for meningococcal vaccination
support the use of either of the vaccines or even a combination. for the general population.
The evidence suggests that the burden of pneumococcal
disease is high in HIV-infected individuals, and vaccination The general indications for vaccine are:
against pneumococcal disease is an important strategy to • functional or anatomic asplenia
reduce this.26 Globally, various advisory committees on • complement deficiency
vaccination differ in their recommendations for vaccination • individuals at risk of exposure through travel or work
against pneumococcus.27 As an example, the United States settings (routine microbiology laboratories)
Advisory Committee on Immunisation Practices (ACIP) and • individuals living in hostels, or university or college
Infectious Diseases Society of America (IDSA) guidelines residences
recommend PCV13 followed by PPV23 in HIV-infected • individuals at risk through an outbreak, including men
adults; however, the evidence supporting this is limited.25 In who have sex with men (MSM) who may be exposed to
contrast, the British guideline recommends vaccination with outbreak strains because of social interactions within the
PCV13 only, irrespective of CD4+ count, viral load or ART global MSM community.
use.28 Available evidence suggests that the use of PPV23 or
PCV13 is safe in HIV-infected individuals on ART or with a Two quadrivalent meningococcal vaccines covering
CD4+ count greater than 200 cells/µL.8,29 serogroups A, C, W135 and Y are currently available in South
Africa. One is a polysaccharide vaccine and the other is a
Vaccination against pneumococcal disease should be protein-conjugated polysaccharide vaccine. Because of the
recommended for all HIV-infected individuals regardless of hypo-immunity associated with repeated doses of the plain
CD4+ count, but ideally when HIV viral load is < 1000 polysaccharide vaccine, it is recommended that HIV-infected
copies/mL.29 This guideline supports the prime-boost individuals receive the conjugate vaccine.36 A two-dose
immunisation approach of first vaccinating with PCV13 primary schedule (given 8–12 weeks apart) is recommended
followed by PPV23 eight weeks later. Alternatively, PCV13 to increase the likelihood of a protective primary immune
can be used alone if available. For those who are to receive response. This should be followed by booster doses every
PPV23 as the primary vaccine, it is suggested that the PPV23 five years. HIV-infected persons should ideally be vaccinated
vaccine be given to those who have achieved ART-driven before their CD4+ cell percent drops to < 25%.37
virologic suppression, regardless of the CD4+ count.
Pertussis vaccines
Meningococcal vaccines There are currently two categories of pertussis vaccines,
Neisseria meningitidis is endemic in South Africa, presenting namely, acellular and whole-cell vaccines.38 Acellular
as meningococcal bacteraemia or meningitis. HIV infection vaccines are developed from one or more highly purified
is an important risk factor for acquiring invasive individual pertussis antigens, and whole-cell vaccines are
meningococcal disease (IMD), with a relative risk 5–13 times based on killed Bordetella pertussis organisms. Although
greater than the general population.30,31,32,33 Epidemiological infants below three months of age are at the highest risk of

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 Page 4 of 8 Guidelines

death from Bordetella pertussis, current epidemiological annually.46 The disease burden is most likely underestimated
evidence shows that it is an important cause of respiratory because of a high incidence asymptomatic infection. The
disease in both adolescents and adults.38,39,40 Despite the main route of infection is faecal-oral, and infection is driven
availability of vaccines and adequate coverage of childhood by poor access to safe water and sanitation services. In Africa,
vaccinations, incidence of the disease continues to increase data on HAV infection are limited but the continent is
in adolescents and adults, possibly because of waning considered to be a highly endemic setting.47 In such settings,
immunity. There are very few studies of adolescent and adult routine vaccination in childhood is not recommended
pertussis in the HIV-infected population, with most of the because of immunity acquired following natural infection.47
data on pertussis coming from children.41 Maternal carriage, Data from South Africa show that antibodies to HAV in Black
HIV exposure of young infants, and incomplete vaccination African adults are almost 100% by the age of 20 years,
seem to be the most important risk factors for childhood whereas only 30% – 40% of White adults are positive for HAV
pertussis. Available evidence indicates that maternal antibodies by the age of 20 years.47
vaccination offers significant protective benefits to both
mothers and infants.39 Men who have sex with men are at a higher risk of acquiring
HAV infection with reported outbreaks in some parts of the
Evidence shows that asymptomatic pertussis infection is world.7,48 The burden of disease in this population group is
more common than symptomatic infection in healthy 1.5–3 times that of the general population especially in the
adolescents and adults.42 More data are needed to understand developed world.49
the epidemiology and the burden of pertussis in countries
where HIV/AIDS is endemic. To date, there are no studies About 13 studies have reported data on HAV vaccination of
with regard to the immunogenicity or efficacy of pertussis HIV-infected adults.46 All these studies explored the immune
vaccination in HIV-infected adults. Evidence from studies in responses to HAV vaccination and reported that the vaccine
children demonstrates that HIV infection lowers antibody is safe and without effect on the clinical progression of
response following vaccination, and high CD4+ counts at HIV infection among adults on ART.46 Vaccination at higher
vaccination improve antibody response.41 With the lack of CD4+ counts is associated with better vaccine-induced
data on the burden of disease in HIV-infected adolescents immune responses. However, given the heterogeneity of the
and adults, the recommendation would be that only pregnant methodology and study populations, these results should be
women, regardless of CD4+ counts or viral load, be vaccinated interpreted with caution.46
(with acellular vaccine) during each pregnancy until there is
more evidence to do otherwise. This is mainly to increase There is no consensus on the benefits of routine vaccination
their antibody levels, so as to enhance transplacental antibody of HIV-infected adults with HAV vaccines. Advisory groups
transfer to their newborns, who are at high risk of pertussis such as ACIP and the WHO Strategic Advisory Group of
illness.43 Experts on Immunisation (SAGE) recommend vaccination
in the presence of other risk factors (medical, behavioural,
epidemiological or occupational risk factors). High risk
Diphtheria and tetanus vaccines groups for HAV infection typically include MSM, injection
Recommendations for the use of tetanus and diphtheria drug users, people travelling to or working in countries
vaccines in HIV-infected adults mirror that for the general with a high or intermediate endemicity of HAV, people
population. Both vaccines are inactivated toxoid and are with chronic liver disease (including hepatitis B or C),
therefore safe for use in HIV-infected individuals. Vaccine- bleeding diathesis, immunosuppressed individuals who
induced immune responses following tetanus vaccination have undergone transplantation and contacts of children
appear to be similar in both HIV-infected and HIV-uninfected arriving from countries with high or intermediate HAV
individuals.44 In contrast, vaccine-induced immune responses endemicity.46
following diphtheria vaccination are lower in the presence
of HIV infection and are influenced by the CD4+ counts.7 We recommend that HAV vaccination should be given if
Studies show that following primary vaccination with there are other medical, behavioural, epidemiological or
tetanus and diphtheria vaccines among HIV-infected occupational conditions in addition to HIV infection. The
children, there is a quick waning of the vaccine-induced accepted schedule is two doses separated by 6–12 months.46
immunity.45
Hepatitis B vaccines
However, as the evidence is lacking on the optimal booster
schedule for HIV-infected adults, the recommendation is Hepatitis B virus (HBV) vaccination is highly recommended
administration of tetanus and diphtheria vaccines at least for individuals with HIV infection. Globally, the introduction
every 10 years until more data are available. of routine HBV vaccination has resulted in a significant
decrease of HBV infection and the overall disease burden.46,50
Co-infection with HBV and HIV is considered endemic in
Hepatitis A vaccines sub-Saharan Africa, including South Africa. Both viruses
Hepatitis A virus (HAV) is the most common cause of acute share the same routes of infection, and it is estimated that the
viral hepatitis, with approximately 1.4 million clinical cases prevalence of chronic HBV in HIV-infected individuals

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ranges from 0.4% to 23% in South Africa.51 The overall global evidence to guide booster vaccine dosing in HIV-infected
prevalence of co-infection is around 10%, but this estimate individuals.61
varies from region to region. The rates of HBV infection
among HIV-infected individuals are estimated to be 20 times In South Africa, HPV vaccination is routinely recommended
higher than among HIV-uninfected persons.46,52 for preteen girls aged 9–13 years, regardless of HIV status.
HPV vaccination is recommended for all HIV-infected adult
In South Africa, HBV vaccination has been part of the men and women, and MSM aged up to 40 years, regardless of
childhood immunisation programme since April 1995. CD4+ count, ART use or viral load. In the public sector in
Although vaccination coverage against HBV in childhood is South Africa, the bivalent vaccine is currently in use. In the
high,53 many adults born before 1995 were not vaccinated private sector, the quadrivalent HPV vaccine (4vHPV) is also
earlier in life and remain at high risk of HBV infection.54 available. The 4vHPV was originally tested and approved as
a three-dose regimen, with a dosing schedule of 0, 2 and 6
The administration of vaccines against HBV among HIV- months. More recently, a two-dose schedule (6 or 12 months
infected individuals has been shown to be safe in many apart) has been recommended by the World Health
studies.55 However, immunologic responses are diminished.46 Organization for younger age groups (e.g. 9–14 years at first
A successful response to HBV vaccination is most frequently dose). This is because immunogenicity with two doses in
associated with an undetectable HIV viral load and a CD4+ preadolescent and early adolescent girls was noninferior to
count above 200 cells/µL.56 antibody responses in women aged 16–26 years receiving
three doses.65,66 Should the vaccine schedule be interrupted, it
The international recommendation for administration of is recommended that the vaccination series be completed,
vaccines against HBV is a four-double-dose regimen of a rather than restarted.28
recombinant HBV vaccine (40 µg) at 0, 1, 2 and 6 months.57
However, the WHO recommendation is a three-dose regimen
of recombinant HBV vaccine (20 µg) at 0, 1 and 6 months.55 Poliovirus vaccines
The double-dose regimen induces higher peak anti-HBs There are very little data on wild-type poliomyelitis in HIV-
antibody titres than the standard-dose regimen, but no clear infected individuals. Poliomyelitis is exceedingly rare in
difference in the proportion of adults with protective South Africa but continues to occur in a few countries in the
antibodies up to five years after vaccination.8,58,59,60 The British world. The live attenuated oral polio vaccine should be
HIV Association (BHIVA) and the ACIP both recommend avoided in immunocompromised HIV-infected individuals
serologic antibody testing one month and six to eight weeks, because of the potential risk of paralytic polio.67 Hence, the
respectively, following administration of the last dose of the inactivated vaccine is recommended.
vaccine.46
As with many other vaccines, HIV-infected adults have
The panel supports the four-double-dose regimen HBV reduced vaccine-induced immune response to inactivated
vaccine schedule. If this is not possible, then the standard polio vaccine,44,68 which is better if the CD4+ cell count is
regimen should be administered. The panel does not above 200 cells/µL.
recommend serologic antibody testing and is only advised
for healthcare workers or others at high risk. We recommend that all unvaccinated HIV-infected adults be
vaccinated with the inactivated polio vaccine, regardless of
Human papilloma virus vaccines CD4+ count, especially if the individuals are travelling to
high-risk regions (such as Nigeria, Pakistan and Afghanistan).
Human papilloma virus (HPV) infection is a common Three doses should be administered at 0, 1–2 and 6–12
infection in HIV-infected adults. The virus is more prevalent months with a further dose after 10 years if at high risk.69
and persistent in HIV-infected adults. The persistence of
certain serotypes of HPV infection is associated with
squamous dysplasia and cancer.61 In 2008, it was estimated Live vaccines
that of the 12.7 million new cancers that occurred worldwide, The use of live vaccines is contraindicated in HIV-infected
around 5% were attributable to HPV infection.61,62 The highest adults, especially if the CD4+ count is below 200 cells/µL,
burden of HPV infection and associated diseases is carried by and/or there is clinical evidence of acquired immune deficiency
women.61,63 syndrome (AIDS). There is evidence that for some live
vaccines, there is a potential for the proliferation of vaccine-
HPV vaccines are safe and immunogenic in HIV-infected related viruses in the host, varicella as an example.70,71
adults.64 As observed with other vaccines, HPV vaccine-
induced immune responses are better in HIV-infected
subjects with CD4+ cell counts greater than 200 cells/µL
Measles, mumps and rubella
and suppressed viral loads. There are limited data on the vaccine
efficacy and durability of protection provided by HPV Measles, mumps and rubella (MMR) vaccines are live and
vaccines in HIV-infected adults, whether vaccinated before therefore contraindicated in individuals with CD4+ counts
or after acquisition of HIV infection. There is also no below 200 cells/µL.

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The ACIP has since 2013 made recommendation about the reported on the safety and modest immunogenicity of two
use of MMR vaccine in HIV-infected adults, provided the doses of varicella vaccine in HIV-infected adults with a CD4+
CD4+ counts are above 200 cells/µL, without laboratory count above 400 cells/µL with a suppressed viral load.73 At
evidence of immunity or past disease.72 A retrospective study present in Africa, there is a lack of varicella epidemiology
from the USA assessing the MMR serostatus of HIV-infected and socio-economic data on the impact of this disease.
adults reported that 15% of HIV-infected adults are Therefore, there are no data on which to base recommendations
seronegative. A seronegative MMR status was associated regarding the use of this vaccine in HIV-infected adults.74
with a longer duration of HIV infection, younger age and
those born after 1957. This study also reported that about 50% Zoster vaccine
of HIV-infected adults seroconverted after MMR vaccination. Reactivation of latent varicella-zoster virus infection leads to
This study found that MMR vaccination did not lead to a debilitating condition: Herpes zoster (HZ; known as shingles).
progression of HIV disease, nor did it impact on HIV disease Despite the increased uptake and use of ART, the incidence of
control.72 This study therefore demonstrated the safety and Herpes zoster remains increased in HIV-infected adults. The
efficacy of MMR vaccination in HIV-infected adults with increased uptake of ART has also resulted in a greater
CD4+ counts above 200 cells/µL and undetectable viral loads. proportion of HIV-infected people living beyond the age of
50 years.7,75,76
Most international guidelines recommend MMR vaccination
in non-immune adults infected with HIV with a CD4+ cell The use of varicella vaccine is recommended in varicella-
count above 200 cells/µL.28,72 susceptible adults, as long as they have a CD4+ count above
200 cells/µL; the same CD4+ threshold is used for MMR and
Varicella vaccines yellow fever vaccines. No transmission of vaccine strain VZV
has been documented in people with HIV infection with
It is estimated that 4.2 million cases of severe varicella a CD4+ count above this threshold. The administration of
infection globally result in hospitalisation or death. Varicella live attenuated Herpes zoster vaccine (LAHZV) to 295 HIV-
zoster virus (VZV) infections and related deaths are common infected adults with a CD4+ count above 200 cells/µL was
in HIV-infected individuals. Most HIV-infected adults will found to be safe and immunogenic, with no cases of vaccine
have evidence of prior infection or immunity. There is an strain infection.75,77
effective vaccine for varicella which is in use in high-income
countries. There are limited data on varicella vaccination in At present, there are no epidemiological data to support the
HIV-infected adolescents or adults, although one study has use of this vaccine in Africa. There is a systematic review

TABLE 1: Vaccination guidelines for HIV-infected adolescents and adults.

Vaccine Indication Safety CD4+ count Doses for unvaccinated Booster Comments
adults
MMR vaccine Measles, mumps or ÿ 200 cells/mL 2 doses (28 days apart) Protection likely lifelong Mainly indicated in measles
rubella seronegative seronegative HIV-infected women of
childbearing age
Pregnancy should be avoided for 1
month after vaccination
Influenza R Any 1 dose Yearly -
Pneumococcal R Any 1 dose - Given with PPV23 but must be given first
Conjugated (PCV13)
Pneumococcal RS ÿ 200 cells/mL 1 dose 5–10 years Given with PCV13 but given 8 weeks
after PCV13
Polysaccharide (PPV23) Can be given to patients with CD4 count
< 200 cells/mL if on ART and VL
suppressed
Maximum 2 booster doses, 1 booster
dose in patients > 65 years. Poor
response if CD4+ cell count < 200 cells/
mL and VL not suppressed
Hepatitis B R Any 4 doses (40 µg) Not clear awaiting -
or evidence
3 doses (20 µg)
Hepatitis A RS – travel, MSM, liver ÿ 200 cells/mL 2 doses 10 years -
disease
Meningococcal RS Any 2 doses 5 years -
Tetanus-diphtheria (Td) R Any - 10 years -
Pertussis-acellular R Any 1 dose 10 years Given in pregnancy combined with
tetanus-diphtheria (DTPa/dTpa)
Poliomyelitis-inactivated RS ÿ 200 cells/mL 3 doses none -
Human papilloma virus (HPV) RS – females, MSM Any 2 doses none -
Varicella NR - - - May be considered if CD4+ count > 400
cells/mL
Zoster RS ≥ 200 cells/mL 1 dose none Only use if CD4+ count ≥ 200 cells/µL
MMR, measles, mumps, and rubella; R, recommended; RS, recommended in selected individuals; NR, not recommended; VL, viral load; HBsAb, hepatitis B surface antibody; MSM, men who have
sex with men.

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 Page 7 of 8 Guidelines

underway to assess the morbidity and mortality of VZV  7. Crum-Cianflone NF, Wallace MR. Vaccination in HIV-infected adults. AIDS Patient
Care STDs. 2014;28(8):397–410. https://doi.org/10.1089/apc.2014.0121
infection.74 Until more evidence becomes available, we do not
 8. Kerneis S, Launay O, Turbelin C, Batteux F, Hanslik T, Boelle PY. Long-term immune
recommend this vaccine for HIV-infected adults. responses to vaccination in HIV-infected patients: A systematic review and meta-
analysis. Clin Infect Dis. 2014;58(8):1130–1139. https://doi.org/10.1093/cid/
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gaps in our local data will generate research to provide the
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and preparation of the manuscript. Dr John Black, Dr Prashini
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